Private EM Writes
The Role of Emergency Physicians in Private Healthcare System
Dr Ng Fu 吳奎醫生
I retired from the Hospital Authority in 2019 after more than 30 years’ service in public health with most of the time as emergency physician (EP) in various Accident and Emergency Departments of the Hospital Authority. I then work in an urgent care centre in a private hospital. This private service experience opens my eyes in the private healthcare industry in Hong Kong. Below are some of my personal thoughts about the role of private EPs. The scope is and should be much wider than what I perceive so far.
EPs in private may have different roles in the private healthcare industry. Some EPs set up their own GP Clinic and work like family doctors but they have the advantage of being skillful in doing minor surgery at the Clinic. Some may also admit patients into private hospital and do ward rounds just like what we do in Emergency Medicine Wards.
Some EPs may join large medical groups with patient number more guaranteed and the role is similar to a GP Clinic doctor. But some of them may need to work in unsocial hours and to take emergency calls.
Some EPs may set up or join the business in emergency medical transport of patients within HK or across the border or between countries either as full time or as part time. They may need to work independently outside HK and have social connections to run the business.
Most private EPs join the 24h OPD or urgent centres or even private A&E in private hospitals. The work here is more or less similar to our work in public A&E Departments but with no FSD ambulance patients. Here most of us are required to work in shifts. Some Departments may employ EPs to do long night duties with a good salary package so that other EPs in the Department only need to do A or P shifts. Many a time, the on duty EPs need to cover emergency resuscitation calls of the Hospital to make sure that any patients inside the Hospital in case of deterioration can have expert resuscitation care at short period of time. The advantages of working in private hospitals are multiple: patient load is more or less guaranteed; EPs do not require to take care of non-clinical work like employing nursing or clinic assistant staff; no need to care about medications / equipment procurement. There are also well established safety guidelines or protocols for staff to follow. Hospital pharmacists will take care of all medications related work including as the last line of defence for medication errors.
My first impression when I became a private EP is the enthusiasm of doctors to see patients and the willingness of them to stay after duty hours to clear the queue. The drive behind is obvious in that private EPs have to earn their pay by the number of patients they see and the amount of work they do while HA EPs have fixed salary. My best estimate is that if I work at the same pace as before, I cannot get the same salary as in HA. In order to have a salary return similar to HA package, I need to see patients fast when the queue is long, do various procedures by myself like wound dressing, surgical toilet and suturing (which are done mostly by nurses in public), to admit patients under my care and to do daily ward rounds outside my shift hours. In general, the more procedures you are competent with, the more you may earn. But you still need to apply from the Hospital for the privilege right (which is not easy) to do the procedure (say, OGD) in the Hospital even if you know how to do it. For some private hospitals, you need only to admit patients under another specialist and you do not need to do ward rounds in order to have a reasonable pay.
There are no formal meal times during my shift hours but if there are not many patients waiting, I may go for a meal. This meal time may mean a few less patients I can see during my shift hours. There is also no paid vacation leave since I am not an employee of the Hospital. I may still take vacation leave at the expense of my pay as long as the other colleagues can take up your work during the period. There are no House Officers in the Hospital. When my warded patients’ condition changes, I need to give immediate instructions to the ward nursing staff and at times, I may need to come back to see them as soon as possible. In essential, I am 24 hours on call when I have patients in wards. Life is not easy in the private market.
Complaints from patients and relatives are more than you encounter in public service. Patients need to pay for your service though many of them have medical insurance but usually the charge is not 100% recovered from insurance. If your service is not to their satisfaction or to their expectations, they will not hesitate to complain you to the Hospital management or to the Medical Council or to others. You need to have high EQ, high IQ and high AQ to deal with these complaints. Appropriate professional insurance is indispensable. For minor complaints, it is better to settle before they go wild. However, prevention is always better than cure. We need to anticipate complaints and always warn patients about possible complications especially those from procedures we do on them. Better communications with your patients is important but not a guarantee against complaints. Good mediation techniques may help. Money may work in most of the minor complaints just like in other service industries and you may need to pay out of your pocket. When things go wild, advice from your professional insurance is the final line of defence especially when it is necessary to go to Court.
Professional integrity is always important in our patient care and this is particularly true when we deal with medical insurance claims between patients and the insurance companies. Our medical record should be accurate and precise. Any significant amendments after patient discharge need to follow the Hospital guidelines. I still remember the advice from my medical professors during my medical class that we should protect our medical licence at all costs and not to do stupid things to ruin the licence.
On the other hand, there are lots of good things in the private health industry. Besides a better pay for a diligent EP, there are a lot to offer to our patients in general. Investigations including imaging are fast and diagnoses may be confirmed in a very short period of time. Consultations to other specialists are very welcome and the support is swift and patients may have definitive care in 1-2 days like appendectomy or ESWL for ureteric stones. For patients with unstable acute problems with lots of underlying long term diseases, it may be a challenge for private EPs to find an appropriate place for them balancing the estimated cost for the care and the patient/ relatives’ affordability. The cost of staying in high dependency unit or even ICU is sky high and usually not easily affordable by ordinary family. We need to explain to the patient / family the various options available and to help them make the tough decision whether to have the care in the public first. If the family turns out to stay, then the Hospital can summon appropriate specialist(s) to provide just-in-time medical service to the patient, say in acute coronary syndrome or in acute cerebral stroke. I have witnessed a very swift recovery in these patients after the joint care from an appropriate team of specialists in private.
Work life balance in private EPs is definitely a challenge. We need our family members to understand the nature of our work and the duty of care to our patients. The key word is “balance” – balance between our time with patients and our time with family / life, balance between our salary and our leave / free time, and balance between work and exercise. Life is still beautiful here in the private healthcare industry. Thanks to the pioneer work of our College President, Dr. Clara Wu, we now know that EPs can contribute our expertise and talents in both the public and the private healthcare industry.